Abdominoperineal Resection
4511045395wRVU: 32.18 — Laparoscopic APR with colostomy45123wRVU: 18.39 — Perineal approach only (perineal proctectomy without abdominal component)
Low rectal carcinoma / anal canal carcinoma not amenable to sphincter-preserving resection
Same
Abdominoperineal resection (APR) with permanent end sigmoid colostomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [low rectal/anal canal] cancer located [___] cm from the anal verge, [cT_N_M_]. [Neoadjuvant chemoradiation was completed.] Given tumor location below the levator ani / involvement of the sphincter complex, sphincter-preserving resection was not feasible. The patient presents for abdominoperineal resection. The risks, benefits, and alternatives were discussed with the patient including permanent stoma formation, and informed consent was obtained.
The tumor was located [___] cm from the anal verge, below the levator ani [/ with invasion of the [internal/external] sphincter]. The mesorectum was [intact/previously irradiated and fibrotic]. Pelvic sidewalls were [free/with adherent tissue requiring sharp dissection]. No evidence of [hepatic/peritoneal] metastases. [Additional findings or none].
The patient was brought to the operating room and placed in modified lithotomy (Lloyd-Davies) position to allow simultaneous abdominal and perineal access. General endotracheal anesthesia was induced. A Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics. The anus was closed with a [2-0 Prolene] purse-string suture.
The abdomen was prepped and draped in sterile fashion, extending to include the perineum. A midline laparotomy was performed from xiphoid to pubic symphysis. Abdominal exploration confirmed the operative findings. The small bowel was packed superiorly.
The sigmoid colon was mobilized and the left colon was dissected along the white line of Toldt. The splenic flexure was taken down as needed for adequate colostomy length. The left ureter was identified and swept posterolaterally. The IMA was ligated at [its origin / distal to the left colic artery] with [0-silk ties]. The IMV was ligated at the inferior border of the pancreas.
Total mesorectal excision was performed in the embryologic holy plane. Dissection proceeded posteriorly in the presacral space to the level of the levator ani, anteriorly behind Denonvilliers' fascia, and laterally with identification and preservation of the hypogastric nerves and pelvic autonomic nerves where possible. The lateral stalks were divided.
The sigmoid colon was divided proximally with a GIA stapler. The perineal dissection was then performed simultaneously [or in sequence]. An elliptical perineal incision was made incorporating the anus and [4] cm of perianal skin circumferentially. Dissection proceeded through the ischiorectal fat in all directions. The anococcygeal ligament was divided posteriorly at the coccyx. The levator ani muscles were divided bilaterally. The anterior dissection was carried behind the prostate/vaginal wall and the specimen was delivered through the perineum. The specimen was confirmed to be intact with an adequate soft tissue margin.
The perineal wound was copiously irrigated. The levator ani was approximated in the midline with [0-Vicryl] sutures where feasible. The ischiorectal fat was closed with [2-0 Vicryl] interrupted sutures. The skin was closed with [2-0 Nylon] interrupted sutures [or left partially open with a drain].
A permanent end sigmoid colostomy was fashioned through a left lower quadrant trephine previously marked by the wound ostomy nurse. A circular disc of skin was excised. The colon was brought through the trephine without tension and matured with slight eversion (approximately 1 cm above skin level) using interrupted [3-0 chromic] sutures placed through the seromuscular layer and dermis. The colostomy was confirmed to be well-vascularized.
The abdomen was irrigated. Hemostasis confirmed. The pelvic peritoneum was closed with [3-0 Vicryl] if feasible. The abdominal fascia was closed with running [#1 PDS]. Skin closed with [staples]. Ostomy appliance applied.
None
Rectosigmoid specimen with intact mesorectum, anus, and circumferential perianal skin sent to pathology
[___] mL
[One closed suction drain in the perineal wound / pelvis]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Low rectal cancer, *** cm from anal verge
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Abdominoperineal resection with permanent end sigmoid colostomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** rectal cancer *** cm from anal verge. Sphincter-preserving resection not feasible. *** neoadjuvant therapy. Informed consent obtained including permanent stoma counseling.
FINDINGS: Tumor at *** cm from anal verge. TME planes identified. Ureters preserved. Autonomic nerves ***. No metastatic disease.
DESCRIPTION OF PROCEDURE:
Modified lithotomy position. Foley placed. Anus closed with purse-string. General anesthesia. Surgical timeout per protocol.
Midline laparotomy. Left colon mobilized. IMA ligated at ***. IMV divided. TME performed to levator ani. Colon divided with GIA.
Perineal elliptical incision incorporating anus. Levator ani divided bilaterally. Specimen delivered through perineum intact. Perineal wound closed in layers with drain.
End sigmoid colostomy through left lower quadrant trephine; matured and confirmed viable. Abdominal fascia closed with #1 PDS.
ESTIMATED BLOOD LOSS: ***
SPECIMENS: Rectosigmoid with anus to pathology
COMPLICATIONS: None
DRAINS: Perineal drain
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Extralevator APR (ELAPE)
An extralevator APR was performed given [low T3/T4 tumor / circumferential resection margin involvement on MRI / tumor at or below levator insertion]. The perineal dissection was performed with the patient in prone jack-knife position. The levator ani was divided at its bony attachment to the lateral pelvic sidewall and coccyx, rather than within the pelvic floor, yielding a cylindrical specimen. This technique reduces the risk of intraoperative perforation and positive circumferential resection margin. The perineal defect was reconstructed with [primary closure / biologic mesh / gluteal flap / VRAM flap].
Laparoscopic / Robotic Abdominal Phase
The abdominal phase was performed [laparoscopically / with robotic assistance]. Laparoscopic access was established via a [12-mm] umbilical port. The abdomen was insufflated to [15 mmHg]. [Three / four] additional ports were placed. [The robotic system was docked.] The sigmoid colon was mobilized laparoscopically, the IMA ligated intracorporeally with [clips / vessel-sealing device], and TME carried out in the holy plane to the level of the levator ani. The sigmoid was divided with an endoscopic GIA stapler. The colostomy was matured through a left lower quadrant trephine. Ports were removed and the abdominal wounds closed. The patient was then repositioned [prone jack-knife / modified lithotomy] for the perineal phase, which proceeded as with the open approach. At high-volume colorectal centers, minimally invasive abdominal phase is the preferred approach; the perineal dissection (standard or ELAPE) is unchanged regardless of abdominal approach.
Synchronous Two-Team Approach
The procedure was performed with a synchronous two-surgeon approach, with the abdominal team performing the abdominal dissection and colostomy formation simultaneously with the perineal team performing the perineal dissection. The specimen was delivered through the perineum upon completion of both dissections. Total operative time was reduced with this technique.
Charting Tips
- Document the circumferential resection margin (CRM) assessment on the requisition or note whether the specimen appeared grossly clear. Positive CRM (< 1 mm) is the strongest predictor of local recurrence in rectal cancer.
- Autonomic nerve identification and preservation should be documented. Sexual dysfunction and bladder dysfunction are common postoperative complaints, and documentation of nerve preservation is important for both patient counseling and medicolegal record.
- For perineal wound management, document the closure technique and drain placement. Perineal wound complications (delayed healing, infection, dehiscence) are very common after APR, particularly post-radiation, and the initial wound management should be explicit in the note.
Billing Tips
- Bill 45110 for abdominoperineal resection (APR) with permanent colostomy (29.99 wRVU, 90-day global). Use for standard open APR with synchronous perineal dissection and end colostomy creation.
- Bill 45395 for laparoscopic APR with colostomy. CPT 45110 is the open APR code; 45395 is the laparoscopic equivalent. Document laparoscopic technique, port placement, and any conversion to open. CPT 45112 (perineal proctectomy, perineal approach only) and 45113 (proctectomy with rectal mucosectomy and ileoanal anastomosis, i.e., J-pouch) are distinct operations and should not be used for APR.
- Colostomy creation (44320, 19.41 wRVU) is bundled into the APR codes. Do not bill it separately. The stoma is included in the procedure.
- If a synchronous oophorectomy, hysterectomy, or sacral resection is performed for locally advanced disease, these may be separately billed with modifier -51. Document each additional procedure and its indication.
- 90-day global period: stoma management, pouching education, and routine follow-up within 90 days are bundled. Stoma revision within the global period requires modifier -78 if performed in the OR.